No More Compromises

At home, A.B. is much more independent thanks to power adjustable
seat elevation that enables her to reach items at different heights.

Life is a series of compromises, Gandhi said. Of course, there
are also times in life to say Enough is enough.

That was the situation when it was time to assess client A.B. for a
new power wheelchair. She’d sustained
a C5-6 spinal cord injury as a very
young adult, and in the following years
had built a career with the Kentucky
Office of Vocational Rehab and lived
independently.

In addition to A.B., the seating & mobility team consisted of Cindy
Ramsey, ATP, Numotion; William R.
Mattingly, OTR/L, ATP/SMS, Quantum
Rehab; Crystal Simpson, MS, ATC/L,
ATP, Norton Neurosciences & Spine
Rehabilitation Center; and Brittany
Rowe, OTAS. A.B.’s power chair — with
power tilt and recline, plus manual
swing-away footrests — was more than
five years old, in poor condition and no
longer capable of meeting her physical or functional needs.

During the assessment process, the team determined that A.B.’s
chair was missing some important opportunities to maximize its
owner’s health and independence. “She used the tilt and recline feature
of her chair,” the team notes said. “However, without leg elevation, she
was not able to effectively reposition herself, manage her lower-extremity
edema, or fully redistribute pressure while using the chair.
She had ongoing unstageable pressure
ulcers that required flap surgeries for
closure. In addition, A.B. had a unique
way of using an upward force on her
armrests to assist with postural support
and upper-body positioning/stability
for participation in her activities of daily
living (ADLs) that we had to respect and
incorporate into the system.”

As the team continued to talk, it
became apparent that again and again,
the current power chair compromised
A.B.’s abilities to function optimally
and independently. For instance, A.B.
drove to work from her power chair, but
had a full-time personal care assistant
(PCA) to assist with transfers and ADLs
at home, at work and in the community.
Both her home and office environments
were adapted to enable A.B. to reach
what she needed to from her fixed
wheelchair height. But these arrangements
were far from optimal.

Re: A.B.

Q: Will funding sources pay for seat
elevation?

Seating & Mobility Team: We learned
that third-party payors, including
Vocational Rehab Services, will fund
technologies such as iLevel when they
understand what the beneficiary can
do as a result of it, especially when it is
shown what the person cannot do, or
needs assistance to do, without it.

“She is an effective joystick power
wheelchair driver, and her home and
work environments were accommodated
such that everything was placed
down low for her in a chair with a static
seat-to-floor height,” the team said.
“However, she was not fully integrated
into the workplace, nor was she able to realize her full potential in performing or
participating in her ADLs without access to the
vertical environment.”

That made A.B. more dependent on her PCA
than she needed or wanted to be. She was stuck
at a fixed height in her chair, while the height of
the surfaces she needed to reach varied greatly.
Bed, toilets at home and at work, dresser, closet,
washing machine, kitchen shelves, office desk
shelves, refrigerator, microwave…the list went
on and on.

“As a result,” the team said, “her PCA
performed or assisted with all of A.B.’s tasks,
many of which we felt she had the potential
of performing independently with the proper
technology and training.”

An Uncompromising Solution

To enable A.B. to be more independent, the
team considered a power adjustable seat height
system, in addition to power tilt/recline and
power elevating legrests or a power articulating
foot platform.

In addition to A.B.’s desire to reach different
heights from her chair, the team had to consider that the chair needed
to function in tight quarters at home and at work.

“The overall width of the system posed a challenge,” the team said.
“During the evaluation process, we initially chose a cantilevered-style
armrest with inset brackets to achieve the narrowest system possible
while allowing redundant tissue to be accommodated in the open space
underneath. These had to be changed to a set of dual-post flip-back
armrests [after] delivery to allow for continued functional use of her
power mobility device in the manner she was used to.

“Turning radius and maneuverability of the chair in tight spaces at
home, work and in the community were also a concern. As a result,
a power articulating, elevating foot platform was chosen over power
elevating legrests, as it not only allowed her to move in much tighter
spaces, it also provided much better postural support and stability of
her legs. In addition, she is able to elevate her legs for effective edema
management without a loss of her supported position in the chair.”

PHOTOS COURTESY QUANTUM REHAB & CLIENT.

At work, A.B. can make better use of her office space.

The finished system was a Quantum Rehab Q6 Edge 2.0 power
chair with dual-post flip-up armrests, TRU-Balance 3 power tilt,
power recline, power articulating foot platform, and the iLevel power
adjustable seat height system operated through the Q-logic 2 joystick.
A custom-configured backrest reduces dependence on the armrests for
sitting posture, stability and function.

Ripple Effects

The success of the new system has positively impacted A.B.’s full list of
daily activities.

The team noted, “Power tilt, in combination with power recline and a
power center-mount articulating, elevating foot
platform, has allowed A.B. to independently
reposition herself following transfers, manage
her clothing post toileting, and effectively
reduce pressure over the seated surface, especially
at the skin flap site, to reduce her risk for
the development of another decubitus ulcer.”

The iLevel power adjustable seat height
system enables A.B. to maneuver among the
different surface heights — from shelves in the
grocery store to the stove in her kitchen — she
encounters every day.

“Without iLevel, A.B. was not able to
complete daily toileting activities at home or
work without assistance due to the uneven
surface heights that existed,” the team said.
“By adjusting the height of her seat using
iLevel, transfer training and modified transfer
techniques, she is now able to complete these
activities at an independent level.”

Ironically, A.B. works with people who
have disabilities and discusses the reasonable
accommodations needed in their workplaces.
But she was struggling, the team said, in her
own work environment. “To accommodate her limited reach, her
desk was a ‘mess’ and unprofessional looking, as she could not store
anything on the inaccessible shelves or in the inaccessible cabinets
above it,” the team said. “Her employer feels that providing iLevel has
empowered her to perform eye-to-eye communication as a model for
her clients and adds value to her as an employee. Not only can she reach
and access the area above her desk and make her own copies at the copy
machine, but she is also a much more commanding speaker for the
department behind the microphone as well as in person.”

A static seat height meant A.B. could drive to the grocery store,
but couldn’t reach shelves independently, and couldn’t cook meals by
herself at home. The newly adjustable seat height offered by her iLevel
system now means A.B. can prepare meals and eat independently, and
can dress herself as well. She can even do her laundry independently.

In the end, A.B. and her rehab team decided the time for continual
compromising was over. Rather than A.B. needing to conform to her
environment and forgo so much independence due to a static seat
height, they chose a system that gave A.B. the flexibility to reach higher.

“After final adjustments, A.B. was able to decrease her need for an
assistant at work and at home by being able to complete more ADLs
independently,” the team said. “She also achieved a level of social interaction
in the community she never thought was possible due to iLevel
power seat elevation.

“Access to the vertical environment is vital for a truly successful
client outcome. One shouldn’t assume that limitations are fixed limitations.
A.B. indicated her new power wheelchair, with all of its improvements,
gave her independence that she hasn’t felt in over 14 years.”

This article originally appeared in the June 2016 issue of Mobility Management.